SICKNESS

HEALTH STATUS

Introduction

There are several available yardsticks for measuring intergroup differences in health status:

(1) lifetime longevity, i.e., average expectation of life in years (calculated at birth or other selected points in the age cycle);

(2) annual overall mortality rate, i.e., number of deaths during the year per 1,000 population (the obverse can alternatively be stated in positive terms as the group's annual overall survival rate);

(3) annual mortality rate from a specific disease;

(4) annual morbidity rate from a specific disease, e.g., number of new polio cases during the year per 1,000 population, irrespective of their life or death outcomes in that year. Within all the Jewish populations studied, longevity and annual survival rates are consistently higher for females than for males. In New York City (1949–51) the average annual death rate for Jewish males was 22% higher than for Jewish females.

Lifetime Longevity

Research according to the yardstick of lifetime longevity in the 1960s showed that Jewish women outlived Jewish men in three countries as follows: Israel (1965) – males, 70.7, females, 73.5; Canada (1961) – males, 68.4, females, 72.2; United States (the three cities Detroit, Milwaukee, and Providence, 1963), males, 67.0, females, 71.9.

This pattern is repeated almost universally in the non-Jewish world, despite enormous international contrasts in economic, political, and cultural levels and styles of life. Differences by sex are also visible across almost the entire age spectrum from the first year of life onward, most sharply of all above the age of 45. Also noteworthy is that among both sexes longevity is highest in Israel and lowest in U.S. Jewry. The longevity of Israel male Jews is one of the highest among the nations of the world, exceeded in 1968 by the male life expectancies only of Sweden (71.6), the Netherlands (71.1), Norway (71.0), and Iceland (70.8). On almost all other yardsticks of health status, the latter four Western countries also lead the world. Perhaps the most interesting finding of all emerges upon finer examination of age-specific mortality rates. In all available Canadian and U.S. studies, the Jewish age progression of mortality for both sexes deviates significantly from that of their non-Jewish neighbors. The divergence is most clearly evident in the four stages of the age cycle discernible in a Canadian study conducted in 1940–42 (Spiegelman, 1948).

Stage I. The first year of life. Here, among both sexes, the all-Canadian death rate was 2.5 times greater than for Jewish children. Infant mortality rates are, of course, influenced by differentials in SES (socioeconomic status).

Stage II. Ages 1 through 34. Here, compared to their all-Canadian peers at every age level, the Jewish death rates for each sex separately are consistently about 50% lower.

Stage III. Ages 35 through 54. The Jewish survival advantage continues in each sex, but by steadily shrinking margins with increasing age.

Stage IV. Age 55 and beyond. At age 55 for the first time Jews appear with higher mortality rates than their Christian fellow countrymen. Thereafter, the unfavorable Jewish margin in mortality rates widens progressively with advancing age.

The higher Jewish survivorship rates of U.S. and Canadian Jews from birth to the middle period of life can be explained by the tradition of being health-minded and health-active people, derived largely from their religious practices. The frequent use of medical resources is clearly an advantage for survival below the age of 45–55. It presumably must also operate beyond that point, with the result that the higher rate of Jewish mortality would have been higher still were it not for their greater use of medical resources. Two further facts should be taken into account:

(1) comparing the U.S. and Canadian studies of the 1960s with those of earlier decades, the Jewish tendency to outclimb non-Jewish mortality rates beyond the middle years was seen to become more pronounced;

(2) mortality rates of Israeli males and females in older age were significantly lower than Jews of the same age and sex in the U.S. and Canada. In fact, Israeli life expectancies at age 65 matched those of Swedish females (15.7 and 15.8 years for Israel and Swedish women, respectively) and exceeded those of Swedish males (14.4 and 13.9 years for Israel and Swedish men, respectively).

In subsequent decades, the life expectancy of Jews in advanced countries has been growing by about one year of life every five calendar years, and around the year 2000 it reached 80 years for women and 75 years for men. Although only little different from that of the general population in the corresponding countries or cities, a tendency for infant mortality to be lower among Jews persisted. On the other hand, crude mortality rates of Jews considerably exceed those of the respective general populations, mainly due to the overaged composition of the respective Jewish groups.

[Leo Srole]

MORBIDITY

Any comparison of morbidity between Jews and gentiles must take into account the wide variability of disease patterns among the Jews themselves. This variability stems from the heterogeneous composition of dispersed Jewish communities and the outside influence due to both marriage and conversion. Due to deficient health registration patterns, very little is known about the health status of Jewish or non-Jewish communities in Middle Eastern and North African countries. The information, therefore, can be based only on studies conducted in Israel and on limited studies in the U.S. and in a few European countries.

GENETIC DISORDERS

There are no genetic disorders with either a higher or a lower incidence in all Jews as a group. However, certain diseases are more prevalent among specific Jewish ethnic subgroups as compared to other subgroups and/or gentiles.

Hundreds of years of isolation of relatively small Jewish communities, both from their neighbors and from other Jewish communities, with consequently relatively frequent consanguineous marriages, have contributed to a higher frequency of several genetic disorders within certain Jewish subgroups. These are briefly summarized below:

Ashkenazi Jews

At least six rare metabolic disorders tend to appear more frequently among Jews of eastern European origin than among any other ethnic group in the world. Tay-Sachs disease (infantile amaurotic idiocy), a congenital lethal metabolic disorder with accumulation of lipids in the neurons of both the central and peripheral nervous systems, and manifested by arrest of development, progressive visual loss, and slowly occurring dementia, occurs in 1:6,000 Jewish births in the U.S. as compared to 1:500,000 among non-Jews; Neiman-Pick's disease, a similar condition, manifested by poor mental and motor development, is also more prevalent among Ashkenazi Jews. Gaucher's disease, a rare disorder of lipid metabolism, characterized by splenomegaly, skin pigmentation, bone lesions, and occasionally by hemorrhage and neurological symptoms, is found in about 1:2,500 Ashkenazi Jews; familial disautonomia (Riley-Day's disease), a rare congenital disorder, manifested by poor motor coordination, emotional instability, indifference to pain, inadequate sense of taste, tearless crying, excessive sweating, skin blotching, and frequent upper respiratory infections, has been described almost exclusively in Ashkenazi Jews, with a frequency of about 1:10–20,000. Pentosuria, a harmless, rare anomaly, characterized by an excessive excretion of L-xylulose in the urine, which is usually discovered on routine urinalysis and often mistakenly diagnosed as diabetes, occurs among Ashkenazi Jews in a frequency of 1:2,500–5,000 as compared to 1:40–50,000 among U.S. gentiles. Also, approximately one half of the observed cases of Bloom's syndrome, a rare childhood condition characterized by a marked sensitivity to sunlight, a small stature, and association with chromosomal abnormalities and leukemia, have been described in Ashkenazi Jews.

The first four of these inborn errors of metabolism have been traced back to a circumscribed area in Poland around the city of Bialystok.

Non-Ashkenazi Jews

Several other inborn errors of metabolism are prevalent among non-Ashkenazi Jews. The most prominent of these is a specific variety of hemolytic anemia (increased destruction of red blood cells), particularly upon contact with drugs or ingestion of fava beans. This disorder is based on a deficiency in the enzyme glucose-6-phosphate-dehydrogenase (G6PD), which is required for normal carbohydrate metabolism. The enzyme deficiency reaches a frequency of 58% in Jews coming from Kurdistan, 25% in the rest of Iraqi Jews and slightly lower frequencies in other eastern communities, in contrast with 0.5% in European Jews. Thalassemia, a chronic progressive anemia due to the presence of an abnormal hemoglobin which commences early in life, is also found primarily in Kurdistani Jews. The neighboring community of Iranian Jews has one of the highest world frequencies of the rare liver disorder, Dubin-Johnson's disease, which is characterized by a defect in bile excretion and accumulation of dark pigment granules in the liver. This disorder has recently been traced to Isfahan. Phenylketonuria, a congenital defect in the metabolism of phenylalanine, characterized by the excretion of phenylpyruvic acid in the urine, and which leads to severe mental retardation unless treated early, occurs primarily in Jews originating from Yemen and is practically nonexistent in Ashkenazi Jews. Familial Mediterranean fever (FMF), a disease manifested by repetitive inflammatory attacks of abdominal, pleural and joint pains, as well as by amyloidosis, is prevalent primarily among North African Jews, notably those coming from Libya.

As mentioned above, the presence of closed Jewish communities with frequent consanguineous marriage has enabled the conservation and perpetuation of the abnormal genes for the above conditions. The increase in frequency of inter-ethnic marriage, coupled with a decrease in consanguineous marriage and disappearance of ethnic barriers in Israel and elsewhere, should lead to a dilution of the gene pools and a decline in the overt frequency of these deleterious conditions.

See also *Genetic Diseases in Jew.

ACQUIRED DISEASES

(1) Infectious

It is impossible to valuate innate susceptibility to infectious diseases in any group, since their prevalence is mainly determined by environmental conditions. These include personal habits, public hygienic facilities, and sources of infective agents. In the past, better personal hygiene and adherence to strict rabbinical laws kept trichinosis (a disease transmitted through pork meat), and venereal diseases to an infinitesimal rate in most Jewish communities.

An interesting environmental situation arose in Israel, where each immigrating group brought with it diseases prevalent in its area of origin. Of special concern were schistosomiasis (bilharzia) in Yemenite and Iraqi Jews and filariasis (elephantiasis) in Cochin Jews, because these are debilitating diseases which spread easily under suitable conditions. Trachoma, a severe eye condition, and ringworm infection of the scalp were also of major importance among non-European immigrants. At present Israel resembles western countries with its low profile of infectious disease and with a health pattern similar to the one found in well-developed western countries.

(2) Chronic

Several studies conducted in the U.S. suggested a higher susceptibility of Jewish residents to coronary heart disease. Most probably, this is only partly related to the fact that, in general, Jews in this country belong to a higher socioeconomic stratum. Thus, Epstein et al. observed that the prevalence of the disease among Jewish clothing workers in New York City was twice that among Italians. A more recent study carried out by the Health Insurance Plan in New York City revealed the disease incidence among Jews almost 50% higher than among Catholics and 30% higher than among Protestants. These observations are in contrast with findings among other minority groups in the U.S., such as blacks, who have a relatively lower rate of this disease. It is difficult to assess which of the several known risk factors for coronary heart disease, i.e., diet, lack of physical activity, or stress, is responsible for the increased incidence among Jews. One cannot completely rule out a genetic background as a contributory factor, especially in view of studies indicating a higher susceptibility to the disease among people with certain specific blood groups.

In Israel, coronary heart disease has been constantly on the rise in all population groups. The increase followed the rise in standard of living, continuous stress, and decrease of physical activity. However, the process of assimilation has not yet abolished differences between various ethnic groups within the country. Early studies by Dreyfus, and Toor et al., suggested that Yemenites, and particularly newly arrived Yemenites, have a lower risk of acquiring the disease as compared to European-born Israelis, while veteran Yemenites as well as other non-Ashkenazi Jews in Israel have an intermediate range. These findings are compatible with differences in cholesterol levels between the groups, but again, differences in other life habits such as stress, physical activity, smoking, etc., could contribute to the observed difference in risk.

No definite data with regard to other cardiovascular diseases are available. Buerger's disease, a peripheral vascular disorder affecting primarily young males and manifested by inflammatory and occlusive changes in both arteries and veins, is apparently more prevalent among Jews of eastern European origin, both in Israel and elsewhere. There are some indications that diabetes may be more common among Jews in the U.S., but the data are inconclusive. Cohen suggested that Yemenite Jews have a lower rate of diabetes than other Jewish subgroups, while others observed a higher risk of diabetes among North African-born Jews. Since this is a disease with a certain genetic background, an interaction between heredity and environment could lead to diverse manifestations. It has also been suggested that hypertension and mortality from cerebro-vascular accidents are slightly higher among the North African-born Israelis. This could be related at least in part to a higher incidence of chronic renal disease in this ethnic group, particularly among the females. Regional enteritis and ulcerative colitis, two inflammatory conditions of the bowel, have also been found to be relatively more common among Jews in the U.S. than among gentiles. Jews have always been noted for a lower frequency of drinking. Consequently, both alcoholism and liver cirrhosis are considerably lower among Jews as a group, both in Israel and abroad.

CANCER

There is ample evidence today that several malignant neoplasms occur more frequently in Jews, while others are relatively rare. Furthermore, there is a marked variability in the risk for certain cancer sites within the main Jewish ethnic subgroups. Major cancer sites with a higher risk among Jews are cancer of the colon, breast, and ovary, which have been strongly correlated with higher socioeconomic status, as well as cancer of the pancreas and of the kidney, brain tumors, lymphoma, leukemia, and, among females, cancer of the lung and of the stomach. The higher rate of brain tumors noted among U.S. Jews is consistent with the finding that the incidence of these tumors is higher in Israel than anywhere else in the world.

In contrast, cancer sites occurring less frequently among Jews are the upper respiratory tract, i.e., pharynx, buccal, and the lung (males only), as well as cancer of the bladder, the esophagus (males only) and, to a certain extent, cancer of the prostate. The reason for the varying pattern between the two sexes in lung cancer is probably due to the fact that the most prevalent histological form in this neoplasm differs between the two sexes (odenocarcinoma in females, versus squamous cell carcinoma in males), so that, actually, the lower incidence of lung cancer among Jews is limited to the latter histological form only. The reason for the varying pattern in esophageal cancer is unclear. The one category that has drawn most attention as being rare in Jews is cancer of the uterine cervix. This apparent rarity had been construed as indicating a protective role of circumcision among Jews. More recently, it has been demonstrated that the rarity is limited to Jews of European origin, while in other Jewish communities, notably those originating in Morocco, the incidence may be even higher than that among gentiles in several European countries. The "protective" role of circumcision has also been challenged on the basis of controlled studies in England and the U.S., and by the fact that the disease is not rare in circumcised non-Jewish populations such as in Iran and Turkey. Thus, the low risk of cervical cancer among Jews in the U.S. and Europe as compared to their gentile neighbors is now considered to be related to better personal hygiene and differences in factors associated with sexual behavior, such as age at first intercourse and number of sexual partners. The recent hypothesis of a viral role in the etiology of cervical cancer is also consistent with the pattern of a closed community, and a lower rate of extramarital relationships among Jews until the recent time period. The relatively lower cervical cancer rate among European-born residents in Israel, as compared to the African- and Asian-born, is also consistent with these explanations. On the other hand, the long-term observation of the rarity of cancer of the penis among Jews as a group has not yet been refuted, and there is a strong probability that in this case circumcision may actually play a preventive role.

Community-wide studies of cancer incidence in Israel have demonstrated some parallelism with findings in the U.S. Two facts stand out:

(1) In general the cancer sites that occur more frequently among Jews in the U.S., as compared to gentiles, are more prevalent among the European-born Israelis, while those that occur more rarely among Jews in the U.S. are relatively more prevalent among non-European-born residents in Israel;

(2) The relative incidence of various malignant disorders in European – in contrast to Asian – and African-born groups in Israel shows a striking parallelism to the one of white versus nonwhite groups in the U.S. Since there is no common genetic background for the Israeli and American subgroups, it would seem that the similarities observed may be associated with inter-ethnic differences in socioeconomic status. These findings corroborate previously made observations regarding the role of environmental factors in carcinogenesis. To be more specific, cancer sites occurring more frequently among Europeanborn Israeli residents are colon, breast, ovary, uterine corpus, brain tumors, gallbladder (females only), as well as leukemia and lymphoma in older age. Cancer of the stomach and lung are also higher among the European-born, contrary to the expected pattern of a lower risk of these tumors in higher socioeconomic groups, while cancer of the uterine cervix occurs more frequently among the North African-and to a certain extent, among the Asian-born. Cancer of the esophagus is more prevalent among Jews coming from Iran and Yemen, hepatic cancer among Yemenites, and bladder cancer among North African-born males, while residents coming from the Balkan countries (Bulgaria, Greece, and Turkey) have a considerably higher rate of cancer of the larynx. The two leading sites of cancer in Israel (excluding skin cancer) are lung and stomach in males and breast and stomach in females. This is true for all ethnic categories except for the North African-born females, where cancer of the uterine cervix assumes second place.

The effect of length of residence in Israel, namely the role of change in daily life habits on cancer incidence, has only partly been studied so far, due to lack of sufficient data. However, preliminary observations indicate that in all ethnic groups stomach cancer is lowest among the Israeli-born, intermediate in veteran Israelis, and highest in recent immigrants. There are also some indications that leukemia, at least among children, shows a similar gradient, with highest rate among immigrants, intermediate in first-generation Israelis, and lowest in second-generation Israelis. This is consistent with well-documented data elsewhere that cancer among migrants tends to assume an intermediate position between the range in the country of origin and their host country.

The Israel Ministry of Health has released the following figures for recent years:

Patients

Year

1990

1995

2001

Newly diagnosed with cancer during given calendar year

12,952

17,263

22,290

Cumulative no. of cancer patients (old and new cases) at end of given calendar year

33,000

48,231

66,129

No. of patients with newly diagnosed cancer of the trachea, bronchus, or lungs in the given calendar year

960

1,211

1,487

Females with newly diagnosed cancer of the breast during the given calendar year

2,046

2,550

3,222

No. of patients with newly diagnosed cancer of the cervix uteri during the given calendar year